GENERAL INFORMATIONChild's Name *Name called at home *Date of Birth *Place of Birth0 / 25Is child adopted? (Select One)Is child adopted?YesNoDoes child know of adoptive status? (Select One)Does child know of adoptive status?YesNoWhen do parents plan to tell him/her?Does child live with both parents? (Select One)Does child live with both parents?YesNoIf no, what are the arrangements? Do both parents work? (Select One)Do both parents work?YesNoWhat hours do the parent(s) typically work?Who, besides parents, cares for child?Does this person reside in family's home?Language(s) spoken at homeDoes the family go away frequently for weekends?Where did parents attend school?HEALTHGeneral health since birth?Has child ever been hospitalized?Any recent illness?Allergies?Fears?Nervous habits?Bedtime?0 / 10Usual hours of awakening?Eating habits?When toilet trained?Has your child ever been evaluated? (Select One)YesNoDoes your child receive Occupational Therapy? (Select One)YesNoDoes your child receive Physical Therapy? (Select One)YesNoDoes your child receive Speech Therapy? (Select One)YesNoROUTINEFavorite activities?Does he/she like to be read to? Any favorite books?Does he/she see other children regularly? Where?Is he/she able to play alone?For how long?Where does he/she play indoors?Where does he/she play outdoors?How much time during the day does he/she spend with each parent?With whom does child spend greater part of his/her time?What kinds of things do you do together as a family?Does the child have his/her own room?YesNoWho do they share their room with?Names, birthdates and schools of siblings (if applicable)GROUP EXPERIENCEHas the child been a member of a group?YesNoWhere?What do you hope the school experience will offer your child?If there has been any outstanding event in your child's life in the past few months, such as a new sibling, family move, death of a close relative, serious illness or accident of the child or family member, please specify below. We can work most effectively with your child if we are provided with this important information.Submit